Texas State Board of Dental Examiners
Verification of License or Registration USE THIS FORM IF YOU ARE:
A dentist or dental hygienist licensed in Texas seeking licensure in another state which requires verification from the TSBDE
A dental assistant seeking verification of one or more of the following certifications issued by the TSBDE: Registered Dental Assistant (RDA) Certificate (Permit to make x-rays), Nitrous Oxide Monitoring Certificate, Pit and Fissure Sealant Certificate or Coronal Polishing Certificate.
A third party* requesting information about a dentist or dental hygienist’s Board Scores or Dental Assistant Registration. Include a Release of Information signed by the licensee.
333 Guadalupe, Tower 3, Suite 800 Austin, Texas 78701-3942 Phone: (512) 463-6400 | Fax: (512) 463-7452 Website: www.tTSBDE.tx.gov E-Mail:
[email protected]
FEE
$9.00
(* - Third Party can include: current or potential employer, insurance company or the Professional Background Information Service [PBIS] ).
INSTRUCTIONS: 1. Mail this form and your non-refundable fee to the TSBDE at the address listed above. 2. Make Money Order or Check payable to: Texas State Board of Dental Examiners. 3. The fee for each verification letter is $9.00.
FULL NAME: _____________________________________________
DATE: _______________________
LICENSE OR REGISTRATION NUMBER:
Dental License #:
________________________
Dental Hygiene License #:
________________________
Registered Dentist Assistant (RDA) #:
________________________
Nitrous Monitoring Certificate #:
________________________
Pit and Fissure Sealant Certificate #:
________________________
Coronal Polishing Certificate #:
________________________
TOTAL NUMBER OF VERIFICATION LETTERS
NOTE
Your License Number, Registration Number or Certificate Number are listed on your certificate.
# of Verification Letters: __________
Total Amount Due: $___________
YOUR CURRENT E-MAIL & MAILING ADDRESS:
_________________________________________________ Are you submitting a change of address at this time: _____ Yes _____ No
_________________________________________________ _________________________________________________
E-Mail Address: NAME AND ADDRESS WHERE YOU WANT VERIFICATION LETTER(S) MAILED TO:
_________________________________________________
_________________________________________________ _________________________________________________ _________________________________________________
SIGNATURE:_______________________________________________
Verification of License or Registration Request Form – Rev 2
DATE: ____________________
September 1, 2015
